QIDN

Applicant Information

The "Applicant" is the individual or organisation applying on his/her own behalf or the parent, guardian, relative, partner or companion applying on behalf of the "Beneficiary". The referee, social worker etc. is NOT the applicant.

Cheque Payable Name - please ensure that this name is CORRECT.
Failure to do so will likely result in a meaningful delay before an alternate cheque can be issued if the original cheque is refused by the bank because of an incorrect name.

Title

Firstname

Surname

Amount Being Sought

Beneficiary Date of Birth

Cheque Payable Name Confirm that this is the correct name

Landline or Telephone Number

Street Address

Town

County

Post Code

Beneficiary Information

The "Beneficiary" is the the person who is medically ill, the individual or organisation which will benefit directly from the expenditure of the grant.

Is the "Beneficiary" the same as the "Applicant"?

Title

Firstname

Surname

Date of Birth

Relationship to Applicant

Comment (optional)

Referee / Organisation (e.g. GP/PHN/SOCIAL WORKER) Information

Please supply all of the applicant information below.

Title

Firstname

Surname

Name of Organisation (if applicable)

Position in Organisation (if applicable)

Landline or Telephone Number

Street Address

Town

County

Post Code

Information

Please supply all of the required information below.

Type of grant being sought

Has the Beneficiary ever received a grant before from the QIDN?

Type

Date

Amount

In relation to the support, equipment, relief or care being sought in this application, has an application been made to or grant received from the HSE or other source?

Type

Date

Amount

Organisation

Date

Comment (optional)

Supporting Information

Please attach any supporting information below.

Warning! Please be advised that once files are uploaded you have 2 hours to submit the application. If you go over the 2-hour limit, you will be asked to re-upload your supporting information.

You MUST supply a declaration of support by a health professional or social worker with this form, otherwise the application WILL NOT BE CONSIDERED. This should briefly outline the justification for the grant.

In addition, TWO QUOTATIONS must be supplied if the application seeks financial assistance for medical/ mobility equipment or capital expenditure of any type in support of the needs of the beneficiary. For education support, a copy of the invoice of any fees paid for the course must be supplied (mandatory)

Please attach any other supporting document with this form (optional)

Please select one of the following

Please choose who you are

Grant Application

Applicant Information

Beneficiary Information

Referee / Organisation (e.g. GP/PHN/SOCIAL WORKER) Information

Information

Supporting Information

Please select one of the following